Care of Adult Patients in the ICU Clinical Practice Guidelines (2018)

Society of Critical Care Medicine

Reviewed and summarized by Medscape editors

October 04, 2018

Clinical practice guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU were released in September 2018 by the Society for Critical Care Medicine.[1]

Pain

Use an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults.

Use acetaminophen as an adjunct to an opioid to decrease pain intensity and opioid consumption for pain management in critically ill adults.

Use nefopam (if feasible) either as an adjunct or replacement for an opioid to reduce opioid use and their safety concerns for pain management in critically ill adults.

Use low-dose ketamine (0.5 mg/kg IVP x 1 followed by 1-2 μg/kg/min infusion) as an adjunct to opioid therapy when seeking to reduce opioid consumption in postsurgical adults admitted to the ICU.

Use a neuropathic pain medication (eg, gabapentin, carbamazepine, and pregabalin) with opioids for neuropathic pain management in critically ill adults.

Do not routinely use IV lidocaine as an adjunct to opioid therapy for pain management in critically ill adults.

Do not routinely use a COX-1–selective NSAID as an adjunct to opioid therapy for pain management in critically ill adults.

Use an opioid (eg, fentanyl, hydromorphone, morphine, and remifentanil) at the lowest effective dose, for procedural pain management in critically ill adults.

Do not use either local analgesia or nitrous oxide for pain management during chest tube removal (CTR) in critically ill adults.

Do not use inhaled volatile anesthetics for procedural pain management in critically ill adults.

Use an NSAID administered IV, orally, or rectally as an alternative to opioids for pain management during discrete and infrequent procedures in critically ill adults.

Agitation/Sedation

Use light sedation (vs deep sedation) in critically ill, mechanically ventilated adults.

Use either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults.

Delirium

Critically ill adults should be regularly assessed for delirium using a valid tool.

Use a multicomponent, nonpharmacologic intervention that is focused on (but not limited to) reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing, and vision in critically ill adults.

Do not routinely use haloperidol, an atypical antipsychotic, or a statin to treat delirium.

Do not use haloperidol or an atypical antipsychotic to treat subsyndromal delirium in critically ill adults.

Use dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation.

Do not use bright-light therapy to reduce delirium in critically ill adults.

Immobility

Perform rehabilitation or mobilization in critically ill adults.

Sleep Disruption

Do not routinely use physiologic sleep monitoring clinically in critically ill adults.

Use assist-control ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults.

Use either an NIV (noninvasive ventilation)-dedicated ventilator or a standard ICU ventilator for critically ill adults requiring NIV to improve sleep.

Do not use propofol to improve sleep in critically ill adults.

Use a sleep-promoting protocol in critically ill adults.

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